This inspection took place on 10 and 11 September 2018 and was unannounced.

Westhaven is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Westhaven is registered to support up to 52 people. At the time of the inspection, there were 45 people living in the home.

This is the first comprehensive inspection since changes were made to the providers registration, therefore there is no previous rating.

A registered manager was in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. Feedback regarding the management of the service was positive.

We looked at how risk was managed and found that it was not always assessed and managed safely. Personal emergency evacuation plans did not provide sufficient information to ensure people could be safely evacuated in the event of an emergency and staff had not received training in how to use the evacuation equipment.

Medicines were stored safely and protocols were in place for medicine prescribed as and when required. However, sufficient information had not been recorded to ensure medicines administered covertly (hidden in food or drink), were administered safely.

Information regarding applications to deprive people of their liberty was not robustly recorded and it was not always clear whether an application had been made, or an authorisation was in place. However, we found that appropriate applications had been made.

People’s consent was sought regarding their care and treatment. However, mental capacity assessments completed were not always in line with the principles of the Mental Capacity Act 2005. We made a recommendation regarding this in the main body of the report.

Care plans were not always in place to guide staff how to meet all of people’s identified needs. However, the care plans we viewed were detailed and reflected the preferences of the person to enable staff to get to know them as an individual.

People felt safe living in Westhaven and staff were knowledgeable about safeguarding and how to raise concerns.

Records showed that appropriate recruitment checks had been completed to ensure staff were suitable to work with vulnerable people. Some people told us there were not always enough staff on duty, especially at weekends. Since the inspection the registered manager has told us an extra member of staff is now on duty each weekend.

People were supported by staff and external health professionals to maintain their health and wellbeing.

Staff were supported through induction and supervisions, although some staff felt they would benefit from more regular supervisions. Training was provided to help ensure staff had the knowledge and skills to meet people’s needs.

People told us they enjoyed the meals available and that they always had a choice.

Staff were kind, treated people with respect and protected their dignity and privacy. People were encouraged to be as independent as they could be.

People felt able to speak to staff and raise concerns when needed. They were confident they would be listened to. Friends and family could visit at any time and were always made welcome by staff.

People had choice in how they spent their day and were supported and encouraged to make their own decisions. A range of activities were available both within the home and in the local community.

A system was in place to manage complaints appropriately.

Systems in place to monitor the quality and safety of the service were not effective. Audits did not identify all of the concerns we highlighted during the inspection